Timely identification of patients at high risk of extubation failure and implementation of appropriate strategies to prevent post-extubation respiratory failure is a crucial issue for ICU (Intensive Care Unit) physicians (1).
International guidelines suggest that Noninvasive Ventilation (NIV) should be used to prevent post-extubation respiratory failure in high-risk patients (2). Furthermore, a recent Randomized Control Trial (RCT) from Hernandez et al. (3) showed that High-Flow Nasal Oxygen (HFNO) is not non-inferior to NIV in preventing re-intubation at 72 hours in patients at high-risk of intubation.
The recent study conducted by Thille et al. examined the best strategy to reduce the risk of re-intubation among high-risk mechanically ventilated patients, comparing two treatment strategies: HFNO + NIV (PS 8±2, PEEP 5±1; first NIV session for > 4h and at least 12 h/day for 48h) and HFNO alone (flow of 50 L/min and FiO₂ adjusted for SpO₂ > 92%; at least for 48h).
In this multicenter RCT conducted at 30 ICUs in France, 648 adult patients intubated for > 24h and at high risk of extubation failure (> 65 years or with underlying chronic lung or cardiac diseases) were randomized to HFNO + NIV (n = 342) or HFNO alone (n = 306), immediately after extubation. Patients were stratified on PaCO₂ level >45 mmHg.
The primary outcome was re-intubation at 7 days; secondary outcomes included post-extubation respiratory failure at day 7, re-intubation rates up until ICU discharge and ICU mortality.

Research findings showed:

• re-intubation rate at day 7 was significantly lower with HFNO + NIV 11.8% (40/339) 18.2% (55/302) with HFNO alone (difference, -6.4% [95% CI, -12.0% to -0.9%]; p = 0.02).
• A higher proportion of patients showed post-extubation respiratory failure at day 7 in the HFNO alone group compare to HFNO + NIV group (29% 21%; difference, -8.7% [95% CI, -15.2% to -1.8%]; p = 0.01).
• Re-intubation rates up until ICU discharge were significantly lower in the HFNO + NIV group (12%) compare to HFNO alone (20%) (difference -7.4% [95% CI, -13.2% to -1.8%]; p = 0.009).
• ICU mortality rates were not significantly different: 6% HFNO + NIV 9% HFNO alone (difference, -2.4% [95% CI, -6.7% to 1.7%]; p = 0.25).
• Subgroup analysis showed that patients with PaCO₂ > 45 mmHg before extubation had a significantly lower re-intubation rate at 7 days with HFNO+NIV compare to HFNO alone (8% 21%; difference, -12.9% [95% CI, -27.1% to -0.1%]; p = 0.049).

Key points

• The combination treatment with HFNO and NIV may be an optimal strategy to prevent post-extubation respiratory failure and avoid re-intubation for patients at higher risk of extubation failure.
• The combined use of HFNO and NIV to treat selected patients with high-risk of post-extubation respiratory failure might be considered in ICUs with high expertise with both techniques.
• Further research is needed to determine the role of this extubation strategy in clinical settings. It would be interesting to compare the combination of HFNO + NIV vs. NIV alone.

References

1) Thille AW, Richard J-CM, Brochard L. The decision to extubate in the intensive care unit. Am J Respir Crit Care Med 2013;187:1294-302.
2) Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;50:1602426.
3) Hernández G, Vaquero C, Colinas L, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients a randomized clinical trial. JAMA 2016;316:1565-74.